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Safety Action

Summary

Local safety action

As a result of their investigation into the incident, the operator implemented the following changes:

1. Introduced new task cards into all Heavy Maintenance B767 major check packs that require the routine deactivation of all door slides at the start of every check and the return to normal configuration on completion.
2. Amended independent inspection requirements to clearly indicate that all parts of the appropriate maintenance manual slide installation task are included.
3. Amended the section of the Flight Readiness Schedule to include door slides for correct flight configuration (girt bar and inflation cylinder regulator safety pin correctly located).
4. Commenced implementing mandatory attendance of the company's Human Factors/Error and Maintenance Resource Management program for all staff.

In addition to these changes, the operator has initiated or completed the following actions related to this occurrence:

1. Reviewed the practice of Senior LAMEs raising discrepancy/supplementary cards for work that has not been performed or supervised by them personally. Additionally, a study is in progress to attempt to identify possible improvements in documentation procedures to include staged signoffs of work completed.
2. Reviewed the supervision level for apprentices and AMEs working on B767 aircraft during Heavy Maintenance checks and briefed staff on the need for focused supervision of less experienced engineers.
3. Notified all Heavy Maintenance staff of the requirement to accurately record all maintenance actions performed, using the appropriate document.

RECOMMENDATIONS

As a result of this investigation, and occurrence investigation number 200101866, the Australian Transport Safety Bureau has identified a safety deficiency related to Boeing jet aircraft cabin door escape slide maintenance documentation. The ATSB therefore issues the following recommendation.

R20010168

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority conduct a review of maintenance documentation for the Australian Boeing jet aircraft fleet to ensure completeness of cabin door escape slide deactivation and reactivation maintenance procedures.

 
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